HomeMy Public PortalAbout5423 ROSEMEAD BLVD_Electrical__ WOIh',COQ/1PENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
s.
hereby affirrmm that I have a'certificatg of consent to-self CE-806G
'ccisure, or-a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified ccoopyy tGh4reof (Sec�3800, Lob. C.)
Policy No. �J&5 Company 51✓�X 5W FOR APPLICANT TO FILL IN JOB pp /j
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS �� /10j�.d9j X11'®
1 & 2-Family, S Ft. $ — $ LOCALITY
ZIWZC-
Certified copy is filed with the cou ty bui g i ec- Y. q•
tion epartment. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools CROSS ST. e^040 y✓A
Date A licar i OWNER OR AA--'' t
PP FIRM NAME �'W �A L��JyFn5
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets: Rec Light Sw._ ^� T
COMPENSATION INSURANCE ADDRESS / 3 ph
s section neenot completed if the work involved b First 20
(Thitid t b
p y Total No. Additional CITY��� 7'�� � Tel. No. 7�j�— 66
the permit is for one hundred dollars ($100)or less.)
1 certifythat in the performance of the work for which this PLAN CHECK
e P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Wor s'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date AppliFixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, VfteorKmaking this Certificate of APPLICANT C�AZ,► G
Exemption, you should become subject to the Workers' Range_ Heater—D.W. —
Compensation provisions of the Labor Code, you must forth- Oven — Dryer — W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. — ��. 7�
deemed revoked. CITY �-ri/p Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan — Other_
f5 0 7—
Disp. _ Room Air Cond. LICENSE OR !b Class. —
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER �/ ;5(/ C
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. 0PROCE55ED BY
and Professions Code, and my license is in full force and effect. _` lr y.
-7 aSize &Type HP, KW, KVA, or KVAR' „ /)/� u 0
License Numb SJ Lic. Class � " /0Up to 1 Incl. w FINAL
3 Over 1 to 10 Incl. DATE VALI ATION
Contractor Date RZ122647
1U4 0
❑ Over 10 to 50 Incl. U
I am exempt FINAL
under Sec. Over 50 to 100 Inc. BYV LM
B.&P.C. for this reaso Over 100 #A
Services, Swbd., MCC& Panelboards ® ';_9 7 7 S 5 A
Date: 0 -200 Amp. Under 600 V VIAI
Signature 201 - 1000 Amp. Under 600 V # 0 0 0 o o 2
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. •( 'o'0 6 3,5 0
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit - 6a505
I hereby affirm that I am exempt from the Contractor's License n Branch Circuits m
Law for the following reason (Section 7031.5, Business and additional SigQ a 2 6 8 7
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name C 1
PERMIT ISSUING FEE J
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
her b outh ' rep entati of this County to enter upon
th ov en on pro a for inspection purpos s.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�6
Si nature ermittee Date